Associate Degree Nursing Program

Quart er
NURS #

Course Syllabus Winter Year 2011

CLASS DATES / TIMES N113 Course Title See Nursing Program quarterly schedule posted on Blackboard. Credits Clock Hours If instructor 4 illness or other emergency forces change in course schedule, students will be notified immediately. Highline (D)
Highline (E) Valley (E) VA (D) St Francis (D) St Francis (E) Anne Kinne Marghee Baldridge JoAnn Mizzi Becky Dolan Sherry Tabor Paula Tusup emai l annekinne@msn.com margheeb@msn.com Jomizzi@yahoo.com beckyanndolan@gmail.com stabor5@gmail.com ptsup@yahoo.com

MISSION STATEMENT We, the Nursing Faculty, are committed to excellence in the nursing profession as exemplified by graduates who are caring professionals that value life-long learning.
PROGRAM OUTCOMES COURSE OUTCOMES Satisfactorily achieve the second quarter Clinical Objectives outlined in the Clinical Outcomes and Quarterly Evaluation Criteria Utilize critical thinking to adapt skills learned in the laboratory to individual clinical situations Utilize critical thinking to adapt nursing care to clients individual needs

Critical Thinking

Communication Abilities

Satisfactorily achieve the second quarter Clinical Objectives outlined in the Clinical Outcomes and Quarterly Evaluation Criteria Identify resources in the clinical area that may be utilized for clients who do not communicate independently in English Assess your learning needs and communicate to your instructor a plan for meeting these needs prior to the start of clinical Satisfactorily achieve the second quarter Clinical Objectives outlined in the Clinical Outcomes and Quarterly Evaluation
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Therapeutic Nursing Interventions

Criteria

Interpersonal Working Relationship Skills

Satisfactorily achieve the second quarter Clinical Objectives outlined in the Clinical Outcomes and Quarterly Evaluation Criteria Identify situation where your client needs you to act as an advocate for them Identify those skills that require teamwork or collaboration with other healthcare team members Utilizes a variety of resources to access information to formulate a plan of care for your clients Behave in an ethical and legally responsible manner

Lifelong Learning Professionalism

METHOD OF INSTRUCTION (Check or X whatever you anticipate using.) Lecture Clinical experiences Computer-assisted learning X
Guest lectures Discussion Small group activities Seminars Test reviews Case studies Lab experiences Worksheets

Independent study Audiovisual materials

Self-evaluation Self-directed methods identified by student Individual guidance and assistance Role playing

X X X

Required reading Recommended reading Written assignments

COURSE ADAPTATIONS & ACCOMMODATIONS Highline Community College provides academic and support services to insure equal access for students with disabilities. Contact Access Services (located in Building 99) to discuss accommodations.

METHODS OF EVALUATION Evaluation of clinical outcomes occurs weekly (formative) with summative (final) ratings at the end of the course. The weekly ratings reflect the instructors professional judgment regarding the students overall achievement of outcomes and provide ongoing feedback to the student regarding current performance and areas in which to improve. CLASS ATTENDANCE There is no make-up for missed clinical days. The students must report the absence to the instructor and the assigned clinical unit PRIPOR to the beginning of the clinical shift. One or more absences may hinder to meet all the course objectives and pass the course.
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RESOURCES: All required nursing texts

HIGHLINE COMMUNITY COLLEGE Associate Degree Nursing Program

SCHEDULE
NURS WEEK 113 DATES 1/25, 1/26 QUARTER Winter YEAR 2011

TOPIC / READING/ EXAMS / PAPERS Clinical Orientation per facility Due Clinical Background Information Sheet Due Quarterly Goals

1 2 3 4 5

1/31, 2/1 2/7, 2/8 2/14, 2/15 2/21, 2/22 2/28, 3/1 3/7, 3/8 Final Conferences

Holiday, no clinical except VA group on 2/22 Due Interaction Analysis Due Clinical Issues Report To be arranged by students and Clinical Instructors

CLINICAL BACKGROUND INFORMATION SHEET

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Please complete this information for your clinical instructor and bring with you to your clinical orientation Name Telephone #

Describe your previous clinical experiences (include facilities and types of patients, observation experiences).

Have you worked in health care settings other than those as a student in Highlines Nursing Program? If so, in what areas and in what capacity?

What are your post-graduation and long-term career goals?

Evaluate your clinical progress so far: on a scale of 1-5 if 1 is weak and 5 is strong Nursing Process

Skills

Clinical Performance

Overall Clinical Abilities Do you have any personal preferences, requests, assets, or limitations of which you would like your clinical instructor to be aware?

In what ways can your instructor be most helpful to you in this course?

HIGHLINE COMMUNITY COLLEGE NURSING PROGRAM N 113 QUARTERLY GOALS/SELF-EVALUATION

Name: Facility: Instructor:

Course: Unit(s):

Quarter:

Year:

Indicate your learning goals for this quarter (3-4 measurable, specific goals with at least 2 activities to help you meet each goal).

Evaluate your progress this quarter toward your goals (include specific details that indicate your achievements or continued learning needs for each).

Describe your strengths in your clinical performance (support with examples).

Describe your areas for continued development in your clinical performance.

List your learning goals for the next clinical course.

Student _______________________________________________________ Instructor _____________________________________________________

Date __________ Date __________ 6

HIGHLINE COMMUNITY COLLEGE NURSING PROGRAM Associate Degree Nursing Program N113 CLINICAL ISSUES REPORT 1. Describe how you individualized your care delivery for one of your clients. Include all factors that apply: cultural background, religious beliefs, personal values, health beliefs and practices, emotional response, developmental issues, lifestyle, socioeconomic status, and support systems. (III-A1, C1) Client initials: Age: M/F Dx:

2.

Describe an actual or possible legal or ethical dilemma related to one of your clients. Develop a plan to resolve this dilemma, including attention to relevant legal standards and ethical principles. (VI-A2) Client initials: Age: M/F Dx:

3.

Identify care tasks from your clinical assignment this week that could be delegated to an unlicensed care provider (e.g., nurse's aide) or an LPN and explain your rationale. (IV-A1)

4.

Give an example of each of the following: an instance where you collaborated with another discipline on a client's care planning or delivery, how you advocated for a client during this clinical course by contributing relevant information to the health care team plan of care, a referral you made to another health care discipline for one of your clients. (IV-B1, 2; E6)

5.

Describe the methods you have used this clinical course to organize your time in clinical; give examples of how these methods have been helpful or not in providing care. (IV-C2)

6.

For a client this clinical course, evaluate that person's readiness to be discharged from this facility, in terms of self-care abilities and knowledge level. (IV-E2) Client initials: Age: M/F Dx:

7.

Identify behaviors that you are practicing this quarter to prevent professional burnout.

(VI-C1)

8.

Describe a clinical care situation for which your facility/unit has an identified standard of care. Explain the standard as defined by your facility/unit. Evaluate the performance you have observed on your unit (including that of yourself, if applicable) according to that standard. Describe a plan to improve care provided on that unit as related to the standard. (VI-D1)

HIGHLINE COMMUNITY COLLEGE Associate Degree Nursing Program N113 INTERACTION ANALYSIS PAPER Student ___MINH PHUNG____________________Instructor__Becky Dolan_____________________________ For questions 1-7, select an interaction you have had this clinical course with a client or clients family member. Client initials NR___ Age/Gender 97/male____ Diagnosis _CAD, COPD______________________________ 1. If this was a planned interaction, list goals for yourself and for your client; if the interaction was unplanned, describe the circumstances of the interaction. What did you hope to achieve during this interaction? The goal was to do Head To Toe Assessment for NR including neuro (heads, eyes, ears, nose and mouth), LOC, skin, thoracic region, abdomen, extremities. 2. Describe the general setting/atmosphere in which the interaction took place. The setting was on his bed and the pt tolerated well during the assessment 3. Describe the main topics that were discussed in the interaction. The main topic was the pulmonary system assessment for his mild SOB problem. He had been CLC for respite care and often c/o mild SOB. Pt often smokes 1 cigarette one day. The main recommendation was quitting smoking, but it was hard for him. 4. Describe the clients nonverbal behaviors during the interaction. Were these consistent or inconsistent with his/her verbal messages? The pt sat quietly without the eye contact during the assessment performance but he made eye contact when I asked him questions. He tried to breath hard during the pulmonary assessment. The nonverbal behaviors were not inconsistent with verbal message. He was alerted and oriented. 5. Describe your behavior, thoughts, and feelings while interacting with the client. How did you convey consistency between your verbal and nonverbal messages? The pt quietly collaborated and did not talk much during the assessment even though he was very talkative during the FHPs interview. He quietly and looked outside the window and expressed no feelings. He asked about the BP and questioned whether it was high or not. I concentrated on doing the Head To Toe assessment with the guideline to prevent the outside topic. 6. List the therapeutic communication techniques you practiced in the interaction. Evaluate the effectiveness of these techniques in promoting communication. If any techniques blocked communication, state how you responded to restore effective communication. The therapeutic communication techniques were quietly listening and sitting face to face with client during the FHPs interview. Pt talked and shared a lot of his stories and experiences. 7. Describe ways you adapted your communication style for your specific client (consider factors such as the clients developmental stage, knowledge level, health beliefs, cultural background, emotional state, etc.). Evaluate the effectiveness of these adaptations. Since NS was the parking attendant and seafood deliver after he finished his military service, I asked him about his experiences and stories from his jobs. I collected FHPs information from that. The effectiveness was fair since I didnt have much knowledge about cars and types of seafood. Hence, he almost dominated the communication.

8.

Describe a conflict you have been involved with during this clinical course. What was the conflict about? How did you and the other party respond? How did you resolve this conflict? The conflict was the misunderstanding of putting the warm coat on the pt for going to the smoking shelter. I got a hard time to put the coat on him since he was unable to spread his arm in standing up position. To solve the problem, I dressed him in the sitting position.

9.

Assess your development of your communication skills over this clinical course. Consider the following criteria as appropriate from the clinical evaluation tool: use of the English language; use of medical terminology; being clear, concise, and complete; adapting communication for the situation and other persons involved; displaying courtesy and respect; being goal-directed, roles in group dynamics. Give examples to support your assessment. Communication with clients/families I feel more confident as communicating with the client by using short sentences with simple common words and no medical terminology. For example, when I dressed Mr. JD, I asked can you raise your arms? and said thanks after he raised his arms. Communications with members of the health care team I feel more confident as communicating with members of the healthcare team by using the respect and thanks for their help. For example, I said thanks to Quinn, the RN nurse at the end of every clinical day. Communications in clinical group discussions I feel more confident as asking questions and discussing clinical issues with classmates by using some medical terminology such as MRSA and NKA. I also showed the respect for the expression and emotions from classmates. For example, Will was kind of showing his sad feeling for caring his hospice pt. I quietly listened to show the sympathy.

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Nursing Clinical Orientation Scavenger Hunt EQUIPMENT/SUPPLIES/LOCATIONS Fire Alarm Exits Respiratory Supplies Medication Room (& Door Code) Clean Utility Room (& Door Code) Pantry/Nourishment Room (& Door Code) Pt/Family Lounge Vital Sign Equipment Catheter Supplies Suction Equipment Restraints Glucometer Syringes Medications sent from Pharmacy Policy/Procedure Books Patient Bed/Room Numbering System Gloves Bed Controls Narcotics Charts/Computer Terminals Patient Kardexes CHARTING Nursing History & Admission Form Progress Notes Operative Reports Radiology Reports Flow-sheets/Assessment Computer charting requirements ROUTINES Shift-to-shift Report Obtaining meds from medication delivery system Obtaining equipment from central supply Changing IV sites, tubing, solutions Unit-specific standing orders Mealtimes Visiting Hours Calling a code Changing tube feeding solutions, tubing Sending specimens to lab Physician History & Physical Physicians Orders Lab Reports Medication Administration Record (MAR) Flow Sheets (VS/Tx, Restraints, I/O, pain assessment) Fire Extinguisher Crash/Code Cart CPR Masks Nurses' Report Room (& Door Code) Dirty/Soiled Utility Room Linen Supplies Shower/tub Room Hygiene Supplies (basin, soap, etc.) Dressing/Wound Care Supplies Tube Feeding Equipment IV Stock Supplies Specimen Testing Supplies Needleless System Equipment Pt. Teaching Resources Resource Books (nursing policies, diet, lab, etc.) Patient Call Bell Needle/Sharps Disposal Box Patient Bathroom Assignment/Unit Census Board Student Assignment Sheets Rest Rooms

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SHIFT REPORT FORMAT Pt Room #/Name *Age/Gender/Dr *Date adm/Dx *Surgeries/Procedures/Date *Important Hx/Major hospital events (*Can be omitted if the oncoming nurse is familiar with the pt) Code status (if not full code) VS/ I&O (if abnormal) Telemetry (if applicable) Abnormal assessments (report normal assessments only if vital to pt or a change from previous findings) Abnormal/important labs HL/IV (soln/rate/amt left/change time) Tubes/dressings/procedures PRN meds given/time/response ADLs/Activity & tolerance (if important/unusual) Pt teaching/DC planning Psychosocial considerations Important changes in orders Misc info important to next shift

END OF SHIFT CHECKLIST For each pt. cared for: Are all meds (routine, 1x, prn) given/charted? Are all flow sheets completed (VS/Treatments, I/O, restraints, assessments, procedures)? Has the care plan been reviewed/updated? Is all relevant info documented in progress notes (pt. teaching, DC planning/readiness, unusual occurrences, pt progress evaluation, etc.)? Is the room orderly with supplies available for the next shift? Is the assignment posted for the next day (if Monday)? Has the RN in charge of the pt been given final report?

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MED-SURG CLINICAL EXPECTATIONS 1. Client/Patient Assignments Each student is expected to go to the hospital the afternoon/evening (not night shift) before a day shift clinical or at least 4 hours before an evening-shift clinical to select one or more appropriate patients. You should avoid shift-change or other unit-specific busy times when staff or patient records are not available to students. Students should be wearing their HCC ID and either full uniform or a lab coat with professional attire (no jeans, sweats, etc.), and should be aware that they are representing themselves as well as the program when they are on-site. Students are prohibited from engaging in any patient care activities while at the facility outside of clinical hours for gathering information. Students are expected to select patients which will provide them with a variety of patient demographics over the clinical course, have conditions which are discussed in concurrent theory courses whenever possible, and will provide learning opportunities for meeting course and personal objectives. You should contact the charge/staff nurse to verify the appropriateness of their selection(s) for a student. You may wish to introduce themselves to the patient to confirm consent to be cared for by a student. Students should post their selected assignments on the assignment sheet as directed during orientation (one sheet per unit per week). In case of duplicate selected assignments, the student whose assignment is posted first on the sheet will care for the patient that weekthe other student will need to select another. Be sure to verify that no other student has posted the same patient (watch for transfers within the unit, which could result in duplication), and be sure that your assignment is accurately posted once you have selected your patient(s). If appropriate, complete the Kardex notifier card also to indicate to staff which patients students have selected. Pre-clinical Preparation Students should review the patients chart to gather information about their selected patient(s). This review should include physicians history and physical/admission notes, physicians and interdisciplinary progress notes, nursing admission history, kardex for current orders, and other parts of the chart which would help the student understand the patients condition, history, reason for admission, and major events since admit (such as operative reports, diagnostic reports, etc.). Students are not allowed to photocopy or print out any of the patients chart. The areas on the Client Care Sheet (CCS) that are underlined need to be completed prior to the start of the clinical shift for all selected patients. Students are also responsible for demonstrating understanding of their written prep during discussions throughout the clinical shift (merely writing what you dont understand is not acceptable prep). The prep areas will be turned in for instructor review at the start of the first clinical shift each week as directed in orientation. Students should use whatever reference materials are appropriate and necessary in their preparation (be sure to indicate sources on the CCS). Particular attention should be paid to understanding the reference/text information as it applies to your specific patient; if you have questions about how the information applies, discuss this with your instructor during clinical. Students should bring reference materials such as a drug book to clinical to use when discussing your patient with the instructor or to respond to changes in the patients condition or physicians orders. As you work with the information about medications, etc. for the patients on your assigned unit, you should be committing more and more of that information to memory, but using reference materials for anything about which you are uncertain is prudent and responsible nursing practice. Students should review any skills/procedures that are anticipated for your selected patient(s), either in your textbooks, the resource lab materials, or through mental rehearsal. Students should also plan a tentative schedule for the shift, taking into account medication and procedure schedules, meal times, and other prescribed activities. 3. Clinical Shift Students should arrive on time to pre-conference or the unit in full uniform with appropriate equipment (e.g., stethoscope, penlight, scissors, watch, and drug book). Students should identify themselves promptly to the co-assigned RN and get report on their patient(s). It is your responsibility to let the RN know what you can and cannot do for your patient, when you need the instructor to be present or their help with anything and what is happening with your patient and your progress in providing care throughout the shift. DONT WAIT FOR THE RN TO COME TO YOU! Students should complete their assessment of their patient early in the shift, and document findings as soon as possible. Keep up with documentation throughout the shift. Be prepared to give status and progress reports to your instructor and RN throughout the shift, including physical assessment findings, vital signs, I/O, IV fluids (solution, rate, time left), need for and response to prn medications, and any psychosocial or teaching issues. Students should report off to the RN whenever leaving the unit, and at the end of the shift. Double-check all documentation (flow sheets, assessments, progress notes, medicationsroutine, onetime, and prn) for completeness and accuracy before leaving. Any changes in assignments for the next day should be posted on the student assignment sheet. If extra time is available, assist your peers or staff with other patients on the unit. 4. Between Clinical Shifts

2.

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Students need to work on documentation and care planning on their CCS between the first and second clinical days. You should not be spending more than 30 minutes during clinical doing school paperwork, so outside work is necessary. Review any information related to changes in your patient(s) on the first day, and revise the shift schedule/plan as needed. The final CCS (1 full per week) will be turned in to your instructor before you leave the second clinical day, so day 2 assessment data, NCP implementation and evaluation, and any day 2 changes in physician orders or medications should be filled in during clinical day 2. 5. Assignment Changes If the assignment changes due to patient discharge or transfer on/before the first clinical day, you will need to select a new patient and start over with the CCS (selecting another patient with the same/similar diagnosis and care if possible will speed this process). Students will need to do sufficient preparation before starting care, but should not spend more than the first 30-60 minutes doing this prep. If it is far enough along in the clinical course and you have demonstrated adequate preparation for and understanding of your previous patients, your instructor may allow you to waive some of the written prep and discuss the information instead. If the assignment changes on the second clinical day, you will select a new patient. You will be responsible for knowing (and writing out, if directed so by your instructor) the following information: major history, diagnosis, and events since admission, rationale for nursing treatments/procedures, and medications (minor classification, indication for use in your patient). You only need to do one full CCS per week.

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CLINICAL CONFERENCE GUIDELINES

The purposes of clinical conferences are as follows: 1. To promote application of theory content to the clinical setting. 2. To engage in discussion of professional issues in preparation for practice. 3. To develop skills in group dynamics, including practice in diverse group roles and abilities in giving and receiving feedback. 4. To develop self-confidence in the professional role, group interactions, and leadership situations. The success of clinical conferences depends on the level of student participation and a willingness of each individual to take responsibility for the process and outcome of the session. Each student is expected to lead at least one clinical conference per quarter. This conference may be an in-service, a group discussion, or a combination of these, depending on the students learning needs for leadership skills. Involving other members of the clinical group in the session as much as possible will help to promote interest and a positive experience. This clinical conference should be at least 20 minutes in length and may cover a variety of clinical topics: Presentation of a patient (or several related patients) with interesting nursing problems, and a discussion of such issues as the development of the nursing care plan, how the patient exemplified or differed from textbook/classroom content, or other topic. Presentation of an in-service on specialized skills, procedures, or equipment. Presentation and discussion of an article from a recent professional journal, magazine or newspaper discussing current trends or events that affect nursing. Presentation or discussion of issues related to cultural awareness and sensitivity in health care. Conducting a problem-solving session related to difficult clinical situations, clinical performance improvement, or other clinical issue. Discussion of legal or ethical dilemmas in patient care. Discussion of examples of critical thinking used during patient care. Discussion of patient teaching topics or discharge-preparation issues. Discussion of psychosocial issues encountered in patient care. Discussion of professional issues and conflicts in the workplace and how these might be constructively managed. Discussion of the various interdisciplinary roles in health care.

This list is just a sample of what may be included in the conference. Check with the clinical instructor for appropriateness of the topic and format for clinical conference. This time is not meant to be a study or test-review session, but is to be related to clinical practice. Be creative and have fun with it!
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HIGHLINE COMMUNITY COLLEGE Associate Degree Nursing Program N113 CLINICAL OUTCOMES AND EVALUATION CRITERIA

STUDENT INSTRUCTOR AGENCY/UNIT WEEKLY INITIALS: 1 2 3 4 5 SUM

QTR

2nd

YEAR TARDY

ABSENT

Evaluation of clinical outcomes occurs weekly with summative (final) ratings at the end of the course. The clinical program outcomes are listed with detailed, leveled, quarterly criteria. A higher score on an outcome cannot be achieved until performance on all criteria related to that outcome meets that higher rating standard. Weekly ratings provide ongoing feedback to the student regarding current performance and areas in which to improve. Summative ratings reflect the instructors professional judgment regarding the students overall achievement of the outcome. Evaluation of written work is included in the rating for the week in which it was submitted. Comments on performance follow the ratings. Instructors keep the official copy and make all entries in ink. Students are required to review/initial the tool each week. RATINGS: 3: Independent: Student requires minimal guidance, cueing, or correction to perform; shows much initiative; uses instructor for validation of problem-solving in new/complex situations 2: Assisted: Student requires moderate guidance, cueing, or correction to perform; shows some initiative; uses instructor for validation of problem-solving in routine/common situations and for assistance in new/complex situations 1: Dependent: Student requires significant guidance, cueing, or correction to perform; shows little initiative; uses instructor for assistance in problem-solving in routine/common situations X: Not applicable: Student absent; Student at observational experience; Not assessed NOTE: Criteria in bold are critical behaviors and must be assessed weekly. The remaining criteria are less frequently occurring, non-critical (but still important), or difficult to ascertain with the usual weekly assessment methods; these will be assessed at least once per clinical course, based on student responses on one-time assignmentsfurther evaluation may be done if additional evaluation opportunities present themselves. Criteria marked with an asterisk (*) in certain quarters will be acceptable at Assisted level (2) at end of quarter, due to insufficient amount of theory content at that level, or historically known length of time required for practice of a certain behavior before independence can reasonably be expected. A Learning or Probationary Contract may be established to focus the student on specific deficits. When a contract is established, the student is given a document that outlines contract terms/processes. Contract criteria include problem areas that impede progress, deficits that indicate possible course failure, or areas with insufficient data to thoroughly evaluate the student. Formative ratings that indicate deficits may result in a clinical contract at any time. At the end of the quarter, a summative rating of less than Independent (or Assisted for any criterion marked with an asterisk {*}) on three to four critical behaviors (criteria in bold type), or three to five non-critical behaviors (in regular type) will result in a clinical contract. A summative rating of less than Independent (or Assisted for any criterion marked with an asterisk {*}) on five or more critical behaviors (criteria in bold type), or six or more non-critical behaviors (in regular type) will result in a clinical course failure. QUARTERLY ASSIGNMENTS: Must each be completed at a satisfactory level or redone (except weekly CCS/NCP) for satisfactory grade in clinical course: Weekly CCS (for each client)/1 NCP Quarterly Goals/Self-Evaluation

Interaction Analysis

Clinical Issues Report

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HIGHLINE COMMUNITY COLLEGE Associate Degree Nursing Program N113 CLINICAL EVALUATION CRITERIA

I.

CRITICAL THINKING A. Uses appropriate thinking skills to effectively define and solve problems 1. Uses appropriate fundamental priorities for basic clinical problem-solving 1 2 3 4 5 SUM

B. Applies specific knowledge and skills to various clinical situations with accurately stated rationale 1. Identifies rationale for client symptoms, test results, treatments, and nursing interventions 2. Identifies rationale for client procedures 3. Provides rationale for nursing interventions that are relevant to nursing diagnosis 1 2 3 4 5 SUM

C. Performs analysis of data: determines relevancy, critiques information and ideas, identifies relationships, draws conclusions, and conducts evaluations 1. Identifies expected assessment findings and relevant nursing care from textbook/references 2. Identifies significant changes in client status from baseline 3. Compares expected findings and plan of care to actual assessments and care needs 4. Demonstrates possible interactions between acute and chronic conditions 1 2 3 4 5 SUM

II.

COMMUNICATION ABILITIES A. Demonstrates proficiency in the English language and health care terminology 1. Utilizes correct grammar and spelling in written and verbal communication 2. Uses medical terminology and approved abbreviations in client charting and assignments 1 2 3 4 5 SUM

B. Communicates with clarity, a sense of purpose, congruence between verbal and nonverbal messages, and respect for others 1. Communicates clearly with clients, families, and other health care providers 2. Appropriately adapts communication style, use of terminology, and content to clinical or professional situation 3. Provides examples of possible discrepancies between verbal and nonverbal communication in self and others 4. Displays courtesy and respect in interpersonal interactions 1 2 3 4 5 SUM

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N 113 CLINICAL EVALUATION CRITERIA (CONTINUED)

C. Uses technology as an aid for written communication 1. Enters and retrieves data from computer data base 2. Uses word processing to complete professional papers 1 2 3 4 5 SUM

III.

THERAPEUTIC NURSING INTERVENTIONS A. Uses the nursing process (assessment, diagnosis, planning, implementation, and evaluation) as a framework for delivery of care to clients in various settings *1. Performs complete assessment using Functional Health Patterns as a framework 2. Accurately identifies 1-2 nursing diagnoses for each client 3. Writes 1 realistic, measurable, client-centered outcome with appropriate deadline for nursing diagnosis 4. Identifies 3 relevant nursing interventions, at least 1 of which is independent, for nursing diagnosis 5. Implement facility-established plan of care 6. Implements at least 2 of own planned interventions 7. Evaluates client according to stated outcome criteria 1 2 3 4 5 SUM

B. Demonstrates proficiency in technical knowledge and skills: psychomotor skills, client education, use of technology, and computational skills 1. Performs skills safely and develops confidence in prior skills 2. Assesses and plans client teaching needs based on client health beliefs, developmental stage, knowledge level, and readiness to learn 3. Safely uses equipment in providing client care 4. Uses mathematics to accurately calculate medication dosages and other numerical client data 1 2 3 4 5 SUM

C. Displays caring behaviors in interactions with clients, such as providing individualized care, showing respect for the diversity of others, being supportive, and promoting maximum independence and wellness 1. Identify factors that influence delivery of client care: cultural background, religious beliefs, personal values, health beliefs & practices, emotional response, developmental issues, lifestyle, socioeconomic status, & support systems 2. Provides care that promotes dignity, comfort, and coping mechanisms of client 3. Keeps client environment organized and safe 4. Encourages client/family participation in care 1 2 3 4 5 SUM

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N113 CLINICAL EVALUATION CRITERIA (CONTINUED)

D. Uses a sound knowledge base as the foundation for delivering care 1. Uses a variety of appropriate resources to develop plan of care 2. Uses text-referenced rationales to defend nursing interventions 3. Integrates theory knowledge with laboratory skills to determine proper care delivery 1 2 3 4 5 SUM

IV.

INTERPERSONAL WORKING RELATIONSHIP SKILLS A. Demonstrates effective leadership skills in delegating tasks, establishing and maintaining effective working relationships with others, and supervising and evaluating other personnel 1. Identifies client-specific tasks that could be delegated 2. Functions as co-leader of group conference session 1 2 3 4 5 SUM

B. Uses collaborative skills, such as teamwork, advocacy for the client, interdisciplinary referrals, and coordination with other health care providers, in providing goal-oriented care *1. Seeks out RN and non-nursing team members to collaborate on plan/delivery of care *2. Advocates for client by contributing information to health care team 3. Seeks out opportunities to assist others 4. Notifies Instructor or staff RN when care requires additional personnel 1 2 3 4 5 SUM

C. Organizes and prioritizes care for the individual and for groups of clients 1. Completes required care on time for 1 client 2. Establishes schedule for activities for shift, using form of choice 3. Discusses staff organizational methods for completing care delivery 1 2 3 4 5 SUM

D. Uses appropriate techniques in conflict management and resolution with individuals and in group dynamics 1. Identifies possible resolution to conflict when it arises 2. Participates actively and facilitates group discussions during clinical conferences 1 2 3 4 5 SUM

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N113 CLINICAL EVALUATION CRITERIA (CONTINUED)

E. Provides for continuity and coordination of care across the health care continuum 1. Identifies where client will go upon discharge 2. Identifies criteria for client readiness for discharge 3. Reports client care situations beyond own skill level to RN or instructor 4. Written documentation and oral reports to instructor and staff are clear, accurate, and focused 5. Coordinates any time off unit with staff RN and reports off to staff RN whenever leaving unit 6. Identifies contributions of non-nursing members of health care team to client outcomes 1 2 3 4 5 SUM

V.

LIFELONG LEARNING A. Effectively uses resources, including technology, to access information 1. Gathers data from a variety of resources, which are current, reliable, and professionally respected 2. Properly documents and credits source of information as appropriate 1 2 3 4 5 SUM

B. Demonstrates self-direction in the assessment of personal needs and abilities, developing a plan for meeting own needs, and applying previous knowledge to current situation 1. Engages in realistic self-assessment of strengths and areas for continued growth 2. Establishes and works toward goals for rotation, relevant to personal knowledge base and performance level 3. Applies prior and concurrent theory content to clinical situation 1 2 3 4 5 SUM

C. Seeks and incorporates feedback from others to foster professional development 1. Integrates feedback from instructor and staff into personal learning goals 1 2 3 4 5 SUM

VI.

PROFESSIONALISM A. Adheres to the legal and ethical standards of the profession 1. Abides by school, agency, and state policies and standards of care and behavior 2. Discusses personal views, relevant legal standards and ethical principles in legal and ethical dilemmas 1 2 3 4 5 SUM

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N113 CLINICAL EVALUATION CRITERIA (CONTINUED)

B. Demonstrates personal responsibility: accountability for own actions, completion of assignments, performance within limitations of personal abilities and scope of practice, self-discipline 1. Completes client care and academic assignments by established dead 2. Limits actions to those on par with personal knowledge level, skill experience and training, and seeks assistance appropriately 3. Is self-motivated in seeking activities and completing assignments 4. Comes adequately prepared for clinical 1 2 3 4 5 SUM

C. Engages in behaviors that promote self-care 1. Identifies symptoms of professional burnout 1 2 3 4 5 SUM

D. Maintains standards of care to promote quality of process and outcomes 1. Critiques performance of self in relation to standards to quality care 1 2 3 4 5 SUM

VII. INDIVIDUALIZED OBJECTIVES This space is for the objectives written by the student on the Quarterly Goals/Self-Evaluation form. Please enter the goals here and rate them weekly. A. ______________________________________________________________________________________________________ B. ______________________________________________________________________________________________________ C. ______________________________________________________________________________________________________ D. ______________________________________________________________________________________________________

1 A. B. C. D.

SUM

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COMMENTS (REQUIRED FOR 1 OR 2 RATINGS; OPTIONAL FOR 3) WEEK OUTCOME # R D COMMENTS

KEY:

# = Criteria not Independent 1, 2, etc. = Week of rotation

R = Rating achieved D = Source of data Sum = Summative rating for the rotation

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COMMENTS (REQUIRED FOR 1 OR 2 RATINGS; OPTIONAL FOR 3) WEEK OUTCOME # R D COMMENTS

KEY:

# = Criteria not Independent 1, 2, etc. = Week of rotation

R = Rating achieved D = Source of data Sum = Summative rating for the rotation

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